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Idr ppt

  1. 1. Bio-materials EFFECTIVE IN PERIODONTAL SURGERY OR NOT ?????
  2. 2. By, Dr.P.R.Ganesh MDS (Perio) Asst.Prof, GDC,Chennai
  3. 3. Age Of Google- Patients are AS informed as we are…
  4. 4. Our thinking should now be Evidence-Based….
  5. 5. So we will see the evidences available for various bio-materials… Critical Appraisal of Publications…
  6. 6. Fast Introduction of Basics…
  7. 7. PERIODONTITIS ? ? ? Deep intra-osseous defect
  8. 8. Periodontitis <ul><li>Inflammatory disease </li></ul><ul><li>Of the Supporting Tissues Of Teeth </li></ul><ul><li>resulting in PROGRESSIVE DESTRUCTION of the Periodontal Ligament </li></ul><ul><li>And Alveolar Bone </li></ul><ul><li>with either Pocket Formation/Recession </li></ul><ul><li>or both. </li></ul>
  9. 9. Pathogenesis-Multifactorial.
  10. 10. DIAGNOSIS- PROBING
  11. 11. TREATMENT <ul><li>Arrest The Inflammatory Disease Process </li></ul><ul><li>By Removal Of The Subgingival Biofilm </li></ul><ul><li>Establish A Local Environment And Microflora </li></ul><ul><li>Compatible With Periodontal Health. </li></ul>
  12. 12. Non-Surgical Therapy Surgical Therapy Perio Treatment
  13. 13. We Are Here To Discuss The Surgical Option For Periodontitis Today
  14. 14. GOALS OF SURGICAL RX Maintain Results Regenerate the Lost Tissue Remove Biofilm
  15. 15. Wound Healing- Outcomes <ul><li>Scarring </li></ul><ul><li>Repair – long junctional epithelium </li></ul><ul><li>Regeneration – New PDL, Cementum, bone </li></ul>
  16. 16. Optimal Outcome Of Treatment- Regenerate The Periodontium To Its Pre-disease State Proven by Histological Evidence of Regeneration – both architecture and function…
  17. 17. To be considered a regenerative modality, a material or technique must HISTOLOGICALLY DEMONSTRATE that bone, cementum and a functional periodontal ligament ( A New Attachment Apparatus ) can be formed on a previously diseased root surface.
  18. 18. Scaling/Root Planing Flap surgery Regeneration <ul><li>Bio-materials: </li></ul><ul><li>New Cementum </li></ul><ul><li>New Periodontal Ligament </li></ul><ul><li>New Bone </li></ul>Repair
  19. 19. World Workshop in Periodontics of the American Academy of Periodontology (1996) <ul><li>Requirements For A Periodontal Treatment To Be Considered A Regenerative Procedure : </li></ul><ul><li>Animal Histological Studies revealing new cementum, periodontal ligament and bone. </li></ul><ul><li>Human Clinical Trials demonstrating improved clinical probing attachment and bone levels; and </li></ul><ul><li>Human Histological Studies - demonstrating new cementum, periodontal ligament and bone coronal to the former defect base </li></ul>
  20. 20. End-point Of Treatment <ul><li>The goal of clinical research is to provide UNEQUIVOCAL EVIDENCE regarding the potential tangible benefits of a treatment. </li></ul><ul><li>Periodontal research cannot afford to keep stopping short of this goal </li></ul>
  21. 21. Bio-Materials Vs. Perio Regeneration
  22. 22. Periodontal Regeneration… <ul><li>GUIDED TISSUE REGENERATION - periodontal regeneration using barrier membranes - in order to avoid the apical migration of epithelium </li></ul><ul><li>INDUCED TISSUE REGENERATION - using specific substances able to induce the regenerative process - growth/differentiation factors or enamel matrix derivatives </li></ul>
  23. 23. Guided Periodontal Regeneration <ul><li>Generation 1 – GTR </li></ul><ul><li>Generation 2- Bio-materials like EMD, BMP, PRP…. </li></ul><ul><li>Generation 3- Growth Factors, Stem Cells, Tissue Engineering.. </li></ul>
  24. 24. Guided Periodontal Regeneration- Many Options available…to confuse us.
  25. 25. Guided Tissue Regeneration Generation 1 – of periodontal Regeneration…. Nyman, Karring et al… Nyman S, Lindhe J, Karring T, Rylander H. New attachment following surgical treatment of human periodontal disease. J Clin Periodontol 1982: 9 : 290–296.
  26. 26. GTR - Rationale <ul><li>To use a physical barrier - barrier membrane </li></ul><ul><li>To selectively guide cell proliferation </li></ul><ul><li>And tissue expansion </li></ul><ul><li>Within tissue compartments </li></ul>
  27. 27. GTR –Barrier Membrane <ul><li>Prevents gingival epithelium and connective tissue expansion </li></ul><ul><li>And favors migration of Cells From The Periodontal Ligament </li></ul><ul><li>And alveolar bone into the periodontal defect. </li></ul>
  28. 28. Gingival Epithelium Connective Tissue Alveolar Bone Periodontal Ligament GTR- Concepts Melcher AH. On the repair potential of periodontal tissues. J Periodontol 1976: 47: 256–260.
  29. 29. Types of Membranes- <ul><li>Non-Resorbable </li></ul><ul><li>Resorbable - Biodegradable </li></ul>
  30. 30. Disadvantages -Non-Resorbable <ul><li>2 nd Surgery Required </li></ul><ul><li>Exposure to Oral environment </li></ul><ul><li>Bacterial contamination </li></ul><ul><li>Failure of collapse in non-cross-linked </li></ul>
  31. 31. Disadvantages -Resorbable <ul><li>Risk Of Exposure </li></ul><ul><li>Collapse Into The Defect Area- Bone Filler Is Needed </li></ul><ul><li>Technique Is Sensitive And Technically Demanding. </li></ul><ul><li>Harmful Degradation Products Of Synthetic Membranes </li></ul>
  32. 32. GTR- Tough, Technique-Sensitive Procedure…
  33. 33. GTR- Disadvantages <ul><li>Other postoperative complications </li></ul><ul><li>swelling, </li></ul><ul><li>erythema, </li></ul><ul><li>suppuration, </li></ul><ul><li>sloughing or perforation </li></ul><ul><li>of the flap, </li></ul><ul><li>membrane exfoliation </li></ul><ul><li>and postoperative pain </li></ul><ul><li>have been reported in independent studies </li></ul>
  34. 34. GTR -Cochrane Systematic Review -16 RCT’s <ul><li>Increase in attachment gain for GTR over open flap debridement - 0.02 to 3.60 mm/mean difference 1.22 mm, 95%CI [0.8,1.64]) </li></ul><ul><li>This value is not a valid estimate of effect because the heterogeneity is substantial and statistically significant. </li></ul><ul><li>A substantial variation in their results – not consistent. </li></ul>IAN NEEDLEMAN, RICHARD TUCKER, Periodontology 2000, Vol. 37, 2005, 106–123
  35. 35. GTR -Cochrane Systematic Review -16 RCT’s- by IAN NEEDLEMAN, RICHARD TUCKER, Periodontology 2000, Vol. 37, 2005, 106–123 <ul><li>Until CONSISTENT BENEFITS from GTR can be shown open flap debridement should remain the control comparison. </li></ul>
  36. 36. Or do GTR and Pray it works out well…
  37. 37. Generation 2 Biomaterial for - Periodontal Regeneration….
  38. 38. What are Bio-Materials? Biologic Mediators - used for Periodontal And Maxillofacial Regeneration
  39. 39. What are Bio-Materials? Partially Purified Protein Mixture From Developing Teeth. Or – Morphogens (Growth Factors) – From Recombinant Technology.
  40. 40. Biomaterials- EMD/BMP/PRP/PRF…..
  41. 41. Ideal Requirements of Bio-materials <ul><li>Biocompatability, </li></ul><ul><li>Enhancement Of Clinical Attachment Levels, </li></ul><ul><li>Reduction Of Probing Depths </li></ul><ul><li>And Hard Tissue Fill Of The Intrabony Defects. </li></ul>
  42. 42. Bio-materials - for Periodontal Regeneration Enamel Matrix Derivatives Bone morphogenetic Proteins Platelet Rich Plasma/Fibrin..
  43. 43. EMD- Enamel Matrix Derivative
  44. 44. EMD- Enamel Matrix Derivative (Emdogain) <ul><li>The </li></ul><ul><li>major (>95%) component of EMD is AMELOGENINS </li></ul><ul><li>Extracellular Matrix Proteins - </li></ul><ul><li>purified acid extract of </li></ul><ul><li>proteins from pig enamel matrix </li></ul>
  45. 46. Enamel Matrix Derivatives… <ul><li>Releases Bioactive Peptides </li></ul><ul><li>Stimulation - Local Growth Factor Secretion And Cytokine Expression </li></ul><ul><li>Induces - Regenerative Process- Amelogenin Deposition Precedes Cementum Formation- Recruitment Of Cementoblasts To The Denuded Root-surfaces . </li></ul>
  46. 47. EMD-EMDOGAIN GEL (Straumann)
  47. 48. Enamel Matrix Derivatives … Systematic Review, 2002- Trombelli et al. <ul><li>Meta Analysis of Froum et al. 2001, Okuda et al 2000, Pontoriero et al. 1999, Silvestri et al. 2000, Tonetti et al. 2002 </li></ul><ul><li>Results showed no evidence of an effect of the predictor on difference in CAL gain between EMD/OFD (P 0.81). </li></ul><ul><li>Change in PPD- 1.60mm (95% CI: 0.59–2.62) </li></ul>Trombelli L, Heitz-Mayfield L, Needleman I, Moles D, Scabbia A: A systematic review of graft materials and biological agents for periodontal intraosseous defects. J Clin Periodontol 2002;
  48. 49. EMD- Cochrane Database of Systematic Reviews, 2009-Esposito M et al. <ul><li>Thirteen trials  - EMD significantly improved PAL levels (1.1 mm) and PPD reduction (0.9 mm) </li></ul><ul><li>High degree of heterogeneity ( ???) </li></ul><ul><li>Sensitivity analysis indicated that the overall treatment effect might be overestimated </li></ul><ul><li>The actual clinical advantages of using EMD are unknown. </li></ul>
  49. 50. Evidence-Based Dentistry  (2003)  4,   Vibeke Baelum and Rodrigo Lopez <ul><li>EMD is able to significantly improve PAL levels (1.3 mm) and PPD reduction (1 mm) compared with flap surgery . </li></ul><ul><li>The authors use absence of statistical significance to conclude that they were unable to explain the heterogeneity found between the studies. </li></ul><ul><li>The CAL improvements attributable to EMD therapy may not have a great clinical impact .  </li></ul>
  50. 51. Clinical Consideration’s <ul><li>Short - Half-life /Biological degradation of material is a concern - ??? </li></ul><ul><li>Whether commercial batches of enamel matrix derivative will be consistent and provide comparable clinical results in all cases??? </li></ul>
  51. 52. EMD- Only Cellular Cementum <ul><li>Instead of the development of AEFC, a partially mineralized connective tissue formed that contained many embedded cells, but no extrinsic fibres. This tissue may thus be classified as bone-like or as a cementum-like tissue- </li></ul><ul><li>But not Acellular Extrinsic Fiber cementum </li></ul>Effects of enamel matrix proteins on tissue formation along the roots of human teeth Dieter D. Bosshardt, Anton Sculean, Niklaus P. Lang J Periodont Res 2005; 40; 158–167. Blackwell Munksgaard 2005
  52. 53. Evidence-Based Dentistry  (2003)  4,   Vibeke Baelum and Rodrigo Lopez Where patients have intrabony defects, is surgery with enamel matrix derivative more effective than other treatments?
  53. 54. Evidence-Based Dentistry  (2003)  4,   Vibeke Baelum and Rodrigo Lopez Currently, the evidence for a possible benefit of EMD in the treatment of intrabony defects IS RATHER WEAK.
  54. 55. No.2 Biomaterial- BMP
  55. 56. Bone morphogenetic proteins recombinant human BMP-2 (rhBMP-2) -introduced by Sigurdsson etal in 1997
  56. 57. BONE MORPHOGENETIC PROTEIN TYPE I COLLAGEN SPONGE (INFUSE; Medtronic Sonfamore Danek, Memphis, TN, USA) Commercial Name….
  57. 58. BONE MORPHOGENETIC PROTEINS <ul><li>A Group Of Regulatory Glycoproteins -That Are Members Of The Transforming Growth Factor-beta Superfamily </li></ul>
  58. 59. In periodontal regeneration <ul><li>Bone Morphogenetic Protein-2 (OP-2) </li></ul><ul><li>Bone Morphogenetic Protein-3 (Osteogenin) </li></ul><ul><li>And Bone Morphogenetic Protein-7 (OP-1) </li></ul>
  59. 60. BONE MORPHOGENETIC PROTEINS <ul><li>Recombinant human bone morphogenetic proteins -used for correcting intrabony, supra-alveolar, furcation and fenestration defects. </li></ul><ul><li>In supra-alveolar periodontal defects, the gains in bone and cementum were 3.5 mm and 1.6 mm, respectively </li></ul>Sigurdsson TJ, Wozney JM, Wikesjo UM. Periodontal repair in dogs: recombinant human bone morphogenetic protein-2 significantly enhances periodontal regeneration. J Periodontol 1995: 66: 131–138.
  60. 61. Disadvantages of BMP <ul><li>Histologic analysis revealed periodontal regeneration with areas of ANKYLOSIS – so now restricted to use around Implants only </li></ul>Cochran DL, Jones AA, Lilly LC, Lilly LC, Fiorellini JP, Howell H. Evaluation of recombinant human bone morphogenetic protein-2 in oral applications including the use of endosseous implants: 3-year results of study in humans. J Periodontol 2000: 71: 1241–1257
  61. 62. I ask for Regeneration and I get ANKYLOSIS????
  62. 63. PLATELET-RICH PLASMA Source Of Growth Factors
  63. 64. PRP ….. <ul><li>Autologous blood is drawn and separated into three fractions: </li></ul><ul><li>platelet-poor plasma (fibrin glue or adhesive); </li></ul><ul><li>platelet- rich plasma; </li></ul><ul><li>and red blood cells. </li></ul>
  64. 65. It Contains….. <ul><li>Platelets are enriched by 338% in the platelet-rich plasma preparation. </li></ul><ul><li>the concentrations of Platelet-derived Growth Factor -41.1 ng/ml </li></ul><ul><li>Transforming Growth Factor-beta1 -45.9 ng ⁄ ml, </li></ul><ul><li>Insulin-like Growth Factor (traces) </li></ul><ul><li>Basic Fibroblast Growth Factor-2 (traces) </li></ul>El-Sharkawy H, Kantarci A -Platelet-rich plasma J Periodontol 2007: 78: 661–669
  65. 66. Platelet-rich plasma <ul><li>Used To Stabilize Graft Materials And Appears To Enhance Early Soft-tissue Healing </li></ul><ul><li>Ineffective For Periodontal Regeneration </li></ul>Dori F, Gera I, Sculean A. Effect of platelet-rich plasma on the healing of intrabony defects treated with an anorganic bovine bone mineral and expanded polytetrafluoroethylene membranes. J Periodontol 2007: 78: 983–990.
  66. 67. Not every Patient is ready for Harvesting their Own Blood…
  67. 68. Discussion Of Periodontal Regeneration..
  68. 69. Discussion.. <ul><li>Proof of principle - many histological studies, mainly performed in animals have provided evidence that various treatment modalities have regenerative potential. </li></ul><ul><li>However, human studies comparing regenerative procedures with the standard of care alone as a control are lacking </li></ul>
  69. 70. Vast difference between animal and Human studies
  70. 71. Surgical variables affecting treatment outcomes <ul><li>Selection Of A Specific Flap Design, </li></ul><ul><li>Location/Morphology Of Bony Lesion, </li></ul><ul><li>And Proper Suturing Technique </li></ul>Periodontal Reconstructive Surgery For Intraosseous Defects Is A Technique Sensitive Procedure
  71. 72. Non-surgical Variables <ul><li>Proper Maintenance </li></ul><ul><li>Smoking </li></ul>
  72. 73. Other Factors to be considered…. <ul><li>The Complexity Of The Periodontium, -Which Consists Of Four Different Tissues </li></ul><ul><li>The Use Of Very High Doses </li></ul><ul><li>The Ideal Carrier </li></ul><ul><li>Enormous Costs - In Relation To Relatively Small And Non-life-threatening Periodontal Disease </li></ul>
  73. 74. Time –out for a review….
  74. 75. Points to Ponder… <ul><li>Although BMP/EMD -contribute to regeneration of the fibrous attachment, their use does not guarantee good results. </li></ul><ul><li>The newly formed cementum that they produce is almost always cellular </li></ul><ul><li>Acellular cementum forms a much stronger bond to dentin than does the cellular type </li></ul><ul><li>Formation Of New Acellular Cementum Is A Key Process In The Regeneration Of Lost Periodontium </li></ul>
  75. 76. Are the regenerated tissues sustainable? For Regenerated Periodontium, The Confirmatory Evidence Would Be Long-term Studies Of The Treated Defects.
  76. 77. Otherwise we would be left with mixed results..
  77. 78. EVIDENCE…….IN/OUT? Enamel Matrix Derivatives Bone Morphogenetic Proteins Platelet Rich Plasma Do they result in Regeneration? Or not?
  78. 79. Is grafting biomaterials or biological agents more effective than open-flap debridement in treating deep intraosseous defects? Trombelli L, Heitz-Mayfield L, Needleman I, Moles D, Scabbia A.   A systematic review of graft materials and biological agents for periodontal intraosseous defects. J Clin Periodontol 2002; 29(Suppl. 3):S117–S135
  79. 80. 26 RCT <ul><li>Most of the included studies </li></ul><ul><li>have been of a rather short duration; </li></ul><ul><li>have comprised rather few patients; </li></ul><ul><li>considerable heterogeneity with respect to their design, methods, organisation, outcomes and maintenance-treatment schemes. </li></ul>Trombelli L, Heitz-Mayfield L, Needleman I, Moles D, Scabbia A.   A systematic review of graft materials and biological agents for periodontal intraosseous defects. J Clin Periodontol 2002; 29(Suppl. 3):S117–S135
  80. 81. Bio-materials/OFD Because of the significant heterogeneity in results between studies in most treatment groups, general conclusions about the clinical benefit of graft biomaterials/biologicals - Need To Be Interpreted With Caution. Trombelli L, Heitz-Mayfield L, Needleman I, Moles D, Scabbia A.   A systematic review of graft materials and biological agents for periodontal intraosseous defects. J Clin Periodontol 2002; 29(Suppl. 3):S117–S135
  81. 82. That evidence seems to be a bit of no-brainer, right?
  82. 83. Currently there is NO EVIDENCE to support the use of these graft materials and biological agents for periodontal intra-osseous defects . Trombelli L, Heitz-Mayfield L, Needleman I, Moles D, Scabbia A.   A systematic review of graft materials and biological agents for periodontal intraosseous defects. J Clin Periodontol 2002; 29(Suppl. 3):S117–S135
  83. 84. Does Statistical Significance Equate To Clinical Significance ??? We very much rely on statistical significance rather than clinical significance.
  84. 85. Expert Advice is In-Valuable….
  85. 86. Conclusions…
  86. 87. Treatment Is Successful…… <ul><li>Reduction Of Probing Pocket Depths, </li></ul><ul><li>Maintenance Or Improvement Of Clinical Attachment Levels, </li></ul><ul><li>And Reduction In Bleeding On Probing </li></ul>
  87. 88. Periodontal Regeneration- ARE WE THERE YET? Clinicians increasingly demand predictable and faster treatment modalities
  88. 89. Results should focus on Patient-centred outcomes and evaluation of cost/benefit ratio.
  89. 90. Conclusions… Differences In CAL Gain And PPD Reduction Vary Greatly With Respect To Different Biomaterial/Biological Agents. Residual defects still remain.
  90. 91. Results These findings question the evidence for a CONSISTENT AND CLINICALLY WORTHWHILE BENEFIT .
  91. 92. Conclusion <ul><li>Regenerative Periodontal Therapies To Date Can Only Restore A Fraction Of The Original Tissue Volume In Extent. </li></ul><ul><li>Complete Periodontal Restoration May Still Be Regarded As An Illusion </li></ul>
  92. 93. Decision Making.. BENEFITS OUTCOMES Vs.
  93. 94. No evidence for use of Biomaterials…Though I am not Einstein…
  94. 95. Future Directions… Future research should focus on developing a clearer understanding of the variability of clinical outcomes
  95. 96. We are on the way to Periodontal Regeneration..
  96. 97. Though there are many difficulties ahead…
  97. 98. Coming in the Future…Wait for it
  98. 99. THIS FIGHT IS JUST BEGINNING
  99. 100. Thank you…. By, Dr.P.R.Ganesh

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